Thursday, September 15, 2016

A New Approach to Designing ALFs

One of our recent grads sent me an article about a new design for an ALF, This Assisted Living Facility Is Designed To Look Like Homes On A Golf Course. Another article, published in the local newspaper, the design is for residents with dementia. Svayus takes a different approach to Alzheimer's explains that this ALF is a place out of time

What they’re about to enter is a world more reminiscent of one that existed in the 1930s and 1940s. The exteriors of the residences are designed to look like homes commonly found during that time period, down to the color of the paint. 

The world of Svayus houses 22 residents, most of whom have Alzheimer’s disease. As the disease progresses, Makesh said, people begin to revert back to their childhood. Svayus serves as something of a time capsule. 

The reasoning behind this is emotional: to provide the residents with a familiar "feel" to their residences. The company has several ALFs designed with the residents in mind. One of them offers this:

Entering into Svayus is like walking outside. In addition to the period-accurate home exteriors, residents are also greeted with a grass-green floor, (artificial) plants, a small waterfall and audio of birds chirping. Overhead is the sky ceiling, designed to help with residents’ physiological clock. During the day, residents will see a sunny sky, even on the grayest Northeast Ohio days. ... 

At night, the sky ceiling darkens and the porch lights come on. 

“Every little thing you see, the wall color, the paint, actually has a therapeutic benefit, a therapeutic value" ...[according to the CEO].

Different aromas also are pumped into the air, providing a therapeutic benefit. Peppermint and frankincense, for example, help with anxiety.  

As far as the ALF designed as though the residents live on a golf course, "rooms designed to look like houses on a golf course. Not only is this aesthetically pleasing, the point is to help residents feel more at home. Compared to your average retirement or assisted living facility, this place looks so much more inviting and calming. The hallway features a ceiling painted like the sky, porches and even porch lights that turn on at night."

Very cool idea. I wonder what one designed for the Boomers would look like? (tie-dye curtains, peace symbols, Beatles posters anyone?)

 

 

 

September 15, 2016 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Housing | Permalink | Comments (0)

Wednesday, September 14, 2016

Patients with Dementia, Pain & Hospice Care

The American Journal of Alzheimer's Disease & Other Dementias ran an article on Pain in Hospice Patients with Dementia: The Informal Caregiver Experience. The abstract explains:

Introduction: At the end of life, patients with dementia often experience high levels of pain due to complex interplay of disease processes and numerous barriers to symptom management. In the hospice setting, informal caregivers play an essential role in pain management. This study describes their experience managing pain in hospice patients with dementia.

Methods: We conducted a qualitative analysis of audio-recorded interviews with informal caregivers of hospice patients with dementia who had chosen pain as the challenge they wanted to work on within a problem-solving therapy intervention.

Results: The thematic analysis of sessions with 51 caregivers identified 4 themes: difficulty in communicating with patients, lack of consistent guidance from health-care professionals, perceived uncertainty about the etiology of pain, and secondary suffering.

Discussion: Our findings indicate the possible need for increased support for caregivers, including educational interventions targeting pain etiology and assessment, and improved communication with health-care professionals.

The full article is available here or as a pdf here.

I thought the points made in the discussion were well-taken. Think about a person with dementia and her ability to communicate regarding her pain level.

[The study] findings indicate that caregivers of persons with dementia in hospice face numerous and significant challenges when it comes to managing their loved ones’ pain. Several studies have already demonstrated that the needs of people with dementia at the end of life are not fully met and that caregivers require more support at this time as they may feel exhausted and alone. Furthermore, while communication between health-care providers and caregivers is important, it does not often take place at times of crisis, affecting overall quality of care... Caregivers described uncertainty about the etiology of pain, difficulties in communicating with patients, lack of consistent guidance from health-care professionals, and secondary suffering as the factors that prevented them from properly and effectively managing pain in their loved ones. Thus, these findings indicate the possible need for increased support for caregivers, including educational interventions targeting pain etiology and assessment, and improved communication with health-care professionals.

Well worth reading!

September 14, 2016 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care | Permalink | Comments (0)

Tuesday, September 13, 2016

Asking The Elder What She Needs Leads to Good Results

A recent study was published in Health Affairs, Home-Based Care Program Reduces Disability And Promotes Aging In Place. The abstract explains:

The Community Aging in Place, Advancing Better Living for Elders (CAPABLE) program, funded by the Center for Medicare and Medicaid Innovation, aims to reduce the impact of disability among low-income older adults by addressing individual capacities and the home environment. The program, described in this innovation profile, uses an interprofessional team (an occupational therapist, a registered nurse, and a handyman) to help participants achieve goals they set. For example, it provides assistive devices and makes home repairs and modifications that enable participants to navigate their homes more easily and safely. In the period 2012–15, a demonstration project enrolled 281 adults ages sixty-five and older who were dually eligible for Medicare and Medicaid and who had difficulty performing activities of daily living (ADLs). After completing the five-month program, 75 percent of participants had improved their performance of ADLs. Participants had difficulty with an average of 3.9 out of 8.0 ADLs at baseline, compared to 2.0 after five months. Symptoms of depression and the ability to perform instrumental ADLs such as shopping and managing medications also improved. Health systems are testing CAPABLE on a larger scale. The program has the potential to improve older adults’ ability to age in place.

A subscription is required to access the full article. A Kaiser Health News (KHN) story about the study, Study Finds Benefits When Seniors Call Shots To Help Them explains "A federally funded project that researchers say has potential to promote aging in place began by asking low-income seniors with disabilities how their lives at home could be better ... At the end of the program, 75 percent of participants were able to perform more daily activities than they could before and symptoms of depression also improved, the researchers said in the journal Health Affairs."

According to the KHN article, the study is based on two ideas: "environment influences health" and elders "should set goals to improve their health." So asking the elder what the elder needs, and then providing the right services leads to a good result, it seems. "Instead of dictating health goals to the patients, the therapist’s first two visits were about listening to what the seniors thought their biggest problems were and creating plans on how to tackle them." The positive impact continued after the study ended, according to one of the researchers interviewed for the article,  who noted environment plays a big role as a barrier to aging in place.

 

September 13, 2016 in Cognitive Impairment, Consumer Information, Current Affairs, Health Care/Long Term Care, Housing | Permalink | Comments (1)

Sunday, September 11, 2016

Just Keep Moving, Even in the Hospital

Have a fitness tracker? A standing desk?  Exercise regularly? If you answered yes to any (or all) of these questions, you know how important it is for us to be active. It turns out that being active is more important than we thought, perhaps.  Kaiser Health News (KHN) ran an article in August, Elderly Patients In The Hospital Need To Keep Moving that features a project at a hospital to keep elders active. The article highlights "the coordinator of a unit designed to address the challenges specific to caring for the elderly. She told her new patient that throughout her stay, one of the main goals would be to keep her active... The medical center’s effort to get older patients up and moving while they are in the hospital is far from typical. Despite a growing body of research that shows staying in bed can be harmful to seniors, many hospitals still don’t put a high priority on making them walk."

Part of the success of such a project is changing the mindset of patients and others.

In addition to employing specially trained staff who work together as a team, the Alabama unit has special handrails attached to the walls, low-glare lighting and non-skid floors. Every room has a walker and plenty of space to move around. Volunteers walk with patients, and therapists work with them on maintaining their strength.

Staff members try to disabuse patients of the idea that they are there to rest. “People walk in the door of a hospital and think it’s OK to stay in a bed. It’s not,” said ["the coordinator of a unit designed to address the challenges specific to caring for the elderly."].

The article notes changing mindsets isn't without challenges, and this project started with changing caregiver attitudes.  Why might there be some reluctance to buy-in to the idea of getting patients moving?  Well, the Affordable Care Act might be one reason: "The Affordable Care Act explains some of the reluctance by staff at many hospitals to get patients moving, experts say. Under the law, hospitals are penalized for preventable problems, including falls. Researchers believe that hospital staffers, to ensure their patients don’t fall, often leave them in their beds." The article offers other reasons, such as lack of staffing or fear of being sued are offered. The physical layout of the hospital room and hospital may be more conducive to patients staying in bed rather than moving about. (think about the beds, the hospital tables, the remote controls, and more).

The results of not moving go beyond the hospital stay.

The impact of remaining so sedentary in the hospital can be devastating for older patients: It is puts them at greater risk for blood clots, pressure ulcers and confusion.

Immobility can also reduce patients’ ability to take care of themselves when they go home — a difficulty that persists a month after their discharge, according to Brown. And it puts them at higher risk of readmission to the hospital, according to research.

Immobility hurts older patients more than younger ones, in part because the elderly are generally weaker, have less bone density and are at higher risk of falling. Ironically, keeping a patient in bed, which is often intended to prevent falls in the hospital, can increase their risk of falling after they are discharged, experts said.

Being more mobile in the hospital can save money, too, as well as improve the patient's health.  So now that you have read this post, put down your computer and go for a walk. See you when you get back!

 

September 11, 2016 in Consumer Information, Current Affairs, Health Care/Long Term Care | Permalink | Comments (0)

"Come Hell or High Water" at the Movies

Over the weekend, I caught the recently released movie, Hell or High Water. Both "contract law" and "elder law" figure into the plot.  Warning: Spoilers ahead -- so don't keep reading if you don't want to know.

The timeless and yet still "modern" plot -- with sons trying to save the family homestead from the bank -- has a few good West Texas twists (although the movie was mostly filmed in my old stomping grounds of New Mexico).  I enjoyed the play on words with the title of the movie from a legal perspective.  The bank's "reverse mortgage" on the homestead has a payoff clause that bars any excuses for nonpayment, such as Acts of God or other hardships.  In legal circles such clauses have are called "come hell or high water" terms, rejecting any "force majeur" excuses for late payments.  So the brothers are up against the clock. Can they steal enough from the very bank conglomerate that made the loan in order for them to get the mortgage paid off by the deadline?  Good character actors abound, including two waitresses who steal the scenes in small town diners and Jeff Bridges at the other end of a Texas journey he began 45 years ago with The Last Picture Show.

The reverse mortgage is the elder law part of the plot.  The movie hints the aging mother was loaned just $25,000 on the homestead (where oil may be found) -- enough to be difficult to pay off (especially with taxes and fees), but not enough money to truly save her from her debts.   While the plot stretches the realities of reverse mortgages, in truth such mortgages are typically very high cost loans, and are not easily refinanced. 

September 11, 2016 in Consumer Information, Current Affairs, Ethical Issues, Housing, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Friday, September 9, 2016

The Surprisingly Complex Law of Descansos (a/k/a Roadside Memorials)

When I was growing up in Arizona, my father and I spent a lot of time on the road, and we would often comment on the small white crosses found along the highways marking the locations of fatal car accidents.  Perhaps this conversation was a bit morbid in retrospect, but the presence of the crosses made an impression on me, demonstrating just how significant a momentary lapse of awareness can be for drivers operating at high speeds.  I'm not sure when those state-sponsored memorials ended, but you still sometimes see markers installed by families. They can vary from simple to elaborate. In the Southwest generally, they are sometimes known as "descansos," a Spanish word for "resting places," and there is a long tradition behind them.  

More recently in Arizona, the tradition has been challenged, with state authorities aggressively removing the impromptu memorials as "safety hazards" in early 2016, citing long-standing laws prohibiting such markers.  An Arizona newspaper chronicled the issues earlier in the year: 

For the past 15 years, Pete Rios would say a special silent prayer as he drove past a large white cross that sat on top of a rocky hill just alongside the road on his way to work.

 

As a little boy, he said, he was told “that’s what you do to show respect” for the many memorial sites that line Arizona highways, marking the deaths of loved ones.

 

One in particular was special to the Pinal County supervisor.

 

It bore the initials of his sister, Carmen Rios, who had been killed near that spot by a drunken driver in 2000. It sat surrounded by a 3-foot angel, faded in color from years of sun beating down on it, and ceramic vases that held new flowers with every passing holiday and changing of seasons.

 

Last week, the memorial disappeared.

When dozens of crosses along Arizona highways disappeared suddenly, families protested.  They countered the "safety" argument, pointing to the absence of any evidence that the small crosses caused drivers to stop or otherwise change their course of driving.  The Arizona Department of Transportation offered "alternatives" as memorials, suggesting families could participate in Arizona's "adopt a highway" program.   

The grassroots advocacy of families took hold, and recently the Arizona Department of Transportation announced a new policy:

Recognizing the need of families to grieve in different ways for those killed in crashes, the Arizona Department of Transportation has established a policy allowing memorial markers along state-maintained highways in a way that minimizes risks for motorists, families and ADOT personnel.

 

Developed with input from community members, the policy specifies a maximum size and establishes standards for materials and placement so markers present less chance of distracting passing drivers or damaging vehicles leaving the roadway....

 

  • Size and materials: A marker may be up to 30 inches high and 18 inches wide, and the wood or plastic/composite material components used to create it may be up to 2 inches thick and 4 inches wide. It may include a plaque up to 4 inches by 4 inches and up to 1/16 of an inch thick. It may be anchored up to 12 inches in the ground, but not in concrete or metal footings.
  • Placement: In consultation with ADOT officials, families will place markers as close as possible to the outer edge of the highway right of way. Markers may only be placed in front of developed property if the property owner gives written permission to the family.

It turns out that states across the nation have different laws and policies governing roadside memorials.  And, I guess I'm not entirely surprised to discover law review articles on this very subject. Florida Coastal Associate Law Professor Amanda Reid has two very interesting pieces, including "Place, Meaning and the Visual Argument of the Roadside Cross," published in 2015 in the Savannah Law Review.

September 9, 2016 in Current Affairs, Discrimination, Ethical Issues, State Cases, State Statutes/Regulations, Travel | Permalink | Comments (0)

Thursday, September 8, 2016

High-Need Patients and the Impact on the Health Care System

The Commonwealth Fund released issue briefs examining "high-need" patients. High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care? is a 14 page issue brief, which is available as a pdf here.  Here is the abstract

Issue: Finding ways to improve outcomes and reduce spending for patients with complex and costly care needs requires an understanding of their unique needs and characteristics. Goal: Examine demographics and health care spending and use of services among adults with high needs, defined as people who have three or more chronic diseases and a functional limitation in their ability to care for themselves or perform routine daily tasks. Methods: Analysis of data from the 2009–2011 Medical Expenditure Panel Survey. Key findings: High-need adults differed notably from adults with multiple chronic diseases but no functional limitations. They had annual health care expenditures that were nearly three times higher—and which were more likely to remain high over two years of observation—and out-of-pocket expenses that were more than a third higher, despite their lower incomes. On average, rates of hospital use for high-need adults were more than twice those for adults with multiple chronic conditions only; high-need adults also visited the doctor more frequently and used more home health care. Conclusion: Wide variation in costs and use of services within the high-need group suggests that interventions should be targeted and tailored to those individuals most likely to benefit.

Looking at this from an elder law perspective, I was interested in the age data in this brief. "High-need adults are disproportionately: ... Older. More than half were age 65 and older; of these, most were 75 and older. In contrast, only about a third of adults with multiple chronic diseases, and less than a fifth of the adult population as a whole, were age 65 and older."

The companion issue brief, Health System Performance for the High-Need Patient: A Look at Access to Care and Patient Care Experiences, is available here as a pdf. The abstract for this brief explains

Issue: Achieving a high-performing health system will require improving outcomes and reducing costs for high-need, high-cost patients—those who use the most health care services and account for a disproportionately large share of health care spending. Goal: To compare the health care experiences of adults with high needs—those with three or more chronic diseases and a functional limitation in the ability to care for themselves or perform routine daily tasks—to all adults and to those with multiple chronic diseases but no functional limitations. Methods: Analysis of data from the 2009–2011 Medical Expenditure Panel Survey. Key findings: High-need adults were more likely to report having an unmet medical need and less likely to report having good patient–provider communication. High-need adults reported roughly similar ease of obtaining specialist referrals as other adults and greater likelihood of having a medical home. While adults with private health insurance reported the fewest unmet needs overall, privately insured high-need adults reported the greatest difficulties having their needs met. Conclusion: The health care system needs to work better for the highest-need, most-complex patients. This study’s findings highlight the importance of tailoring interventions to address their needs.

September 8, 2016 in Consumer Information, Current Affairs, Health Care/Long Term Care, Medicare | Permalink | Comments (0)

Wednesday, September 7, 2016

Boomer Law Partner Retirement?

As Baby Boomer partners retire, law firms face increasing costs and client issues was published in the ABA Journal. The article focuses on the upcoming retirement of law partners from the Baby Boomer and Silent Generations cohorts. "Nearly half of the partners in the nation’s top 200 law firms are Baby Boomers or members of the older Silent Generation. And that means there will be a wave of upcoming retirements that will be the most ever experienced by BigLaw...Sixteen percent of partners will retire in the next five years and 38 percent will retire in the next decade, the American Lawyer (sub. req.) reports...."

The impact of these potential retirements will ripple across law firms, including leadership, client relations, and revenues. The firms will also face other costs-the actual costs of paying for retirements from pensions, revenues, return of capital, etc.  The article also notes that some firms are taking specific steps to weather this retirement wave by "trying to reduce retirement costs by raising the retirement age; capping the annual payout from annual earnings; or changing the payout formula, and switching to defined contribution plans in which the lawyers carry the risk of a declining market."

September 7, 2016 in Consumer Information, Current Affairs, Legal Practice/Practice Management, Retirement | Permalink | Comments (0)

Do You Know Seniors Working in the "Gig" Economy?

My colleague, Becky Morgan, posted recently about the trend of senior-aged consumers as customers of Uber and other ride-hailing companies.   Smart marketing for the alternatives to traditional taxi-cabs includes finding ways for seniors to use and pay for services without smart phones.

Additional research demonstrates that seniors may also play an increasing role in the work force for ride-hailing companies.  They are drivers, not just passengers (both literally and metaphorically).  The latest research from the JP Morgan Chase Institute introduced me to a new label -- the "gig economy," and ride-hailing services are just one part of that economy: 

Our research shows that a rising number of seniors are supplementing their income -- in non-trivial amounts -- by participating in the "gig economy", or Online Platform Economy. . . Among all adults, participation in the Online Platform Economy has been growing very quickly. To measure this growth, we assembled a dataset of over 260,000 anonymized Chase customers who earned income from at least of of 30 distinct platforms between October 2012 and September 2015 -- the largest sample of platform earners to date. During this period, the cumulative participation rate grew from 0.1% of adults to 4.2%. a 47-fold growth.

 

Although most participants in the platform economy are younger workers, seniors are not standing on the sidelines.  In the 12 months ending September 2015, about 0.9 percent of seniors were providers in the

 

 in the platform economy, compared to 3.1 percent of the general population.  With over 47 million seniors in America, this translates to over 400,000 seniors participating in the platform economy. 

 

For those seniors who do participate, their earnings are often substantial.  In our research, we distinguish between labor and capital platforms.  Labor platforms, such as Uber or TaskRabbit, connect customers with freelance or contingent workers who perform discrete projects or assignments. Capital platforms, such as eBay or Airbnb, connect customers with individuals who rent assets or sell goods peer-to-peer.

For more on participation of seniors in the Gig Economy, and for other interesting data points about seniors as both workers and spenders, read Past 65 and Still Working: Big Data Insights on Senior Citizens' Financial Lives, from JP Morgan Chase Institute.

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September 7, 2016 in Consumer Information, Current Affairs, Retirement, Web/Tech | Permalink | Comments (0)

Tuesday, September 6, 2016

The Continuing Problem of Polypharmacy

Kaiser Health News (KHN) ran the story, ‘America’s Other Drug Problem’: Copious Prescriptions For Hospitalized Elderly, focusing on the problems of polypharmacy in elders. Opening with examples of actual patients, one of whom was taking 36 prescriptions,  the story focuses on the issue of elders taking multiple medications and the implications of doing so.

An increasing number of elderly patients nationwide are on multiple medications to treat chronic diseases, raising their chances of dangerous drug interactions and serious side effects. Often the drugs are prescribed by different specialists who don’t communicate with each other. If those patients are hospitalized, doctors making the rounds add to the list — and some of the drugs they prescribe may be unnecessary or unsuitable.

“This is America’s other drug problem — polypharmacy,” said Dr. Maristela Garcia, director of the inpatient geriatric unit at UCLA Medical Center in Santa Monica. “And the problem is huge.”

Among the problems with polypharmacy noted in the article is whether the patient actually needs the drug and the role of medication issues in the patient's hospitalization.  The numbers are high:

Older adults account for about 35 percent of all hospital stays but more than half of the visits that are marred by drug-related complications, according to a 2014 action plan by the U.S. Department of Health and Human Services. Such complications add about three days to the average stay, the agency said.

Data on financial losses linked to medication problems among elderly hospital patients is limited. But the Institute of Medicine determined in 2006 that at least 400,000 preventable “adverse drug events” occur each year in American hospitals. Such events, which can result from the wrong prescription or the wrong dosage, push health care costs up annually by about $3.5 billion (in 2006 dollars).

The article reviews the instances where patients are prescribed additional prescriptions during hospitalization and on discharge, are confused about what medications to take.  Who becomes the "traffic cop" to keep the patients from undergoing drug-related complications?  The pharmacist! Focusing on the inpatient geriatric unit in one hospital, the story explores the importance of the clinical pharmacist's inclusion in a patient's medical team. The featured hospital hired their clinical pharmacist about 3 years ago, according to the story,  with "[t]he idea was to bring a pharmacist into the hospital’s geriatric unit to improve care and reduce readmissions among older patients." How successful has this been?

Having a pharmacist ... on the team caring for older patients can reduce drug complications and hospitalizations, according to a 2013 analysis of several studies published in the Journal of the American Geriatrics Society.

Over a six-month stretch after [the clinical pharmacist] started working in UCLA’s Santa Monica geriatric unit, readmissions related to drug problems declined from 22 to three. At the time, patients on the unit were taking an average of about 14 different medications each.

This seems like a really great idea and hopefully one that will be picked up by other geriatric units.

September 6, 2016 in Consumer Information, Current Affairs, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (1)

Monday, September 5, 2016

"Mission Creep" in End of Life Care?

The Washington Post ran an article last month that looked at the provision of treatments to those who are at the end of life.    Mission creep doesn’t benefit patients at the end of life  explains

Here in America, there is a deeply held belief that advances in medicine will eventually conquer or cure the chronic scourges of cancer, dementia, heart disease, lung disease and diabetes. This notion leads many elderly patients to seek aggressive treatment not only to spare their loved ones grief but because they hope (and expect) to be cured, if only they hold on just a little longer.

So how often is futile care provided? And why?  The story reports "more than 75,000 people older than 85 die in intensive care units seeking care that proves to be futile, according to a 2004 study, and why more than 65 percent of our senior citizens die in institutions when a significant majority say they would prefer to die at home, according to a 2014 report by the Institute of Medicine."  So what does the author mean by "mission creep" when patients make choices?

Not every patient has the option to decline surgery for a threatening aneurysm or chemotherapy for late-stage cancer. Most patients have multiple smaller decisions to make in the mission creep of treatment vs. care. These patients and their families need help thinking about the natural progression of aging and visualizing what they want at the end. Then, if they decline treatment and choose palliative care, they can consider an exit strategy.

So oversimplified, this boils down to a quality vs. quantity discussion. The author recommends that when the patient is an elder, "that conversation should include a discussion about futile treatments vs. making sure the last days on earth are comfortable...." and that "discussions with our trusted physicians should evolve from how to die later to how to die better, including with an exit strategy."

September 5, 2016 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Health Care/Long Term Care | Permalink | Comments (0)

Friday, September 2, 2016

Thinking About References for Current and Recent Law Students

I'm frequently asked by current students or recent graduates to serve as a reference and usually I'm happy to do so.  I like it when students provide me with  basic information, reminding me what classes they took with me, giving me their most recent resume and a copy of their transcript.  Students who have taken the time to chat with me outside of class over the course of their law school careers help me provide relevant information to prospective employers about their strengths and plans.  

Students who showed initiative in their studies earn strong references.  Did the student "coast" with "easy A" courses, or did they seek out the courses truly relevant to their goal positions?  Do they have a polished writing sample?  Have they taken appropriate leadership roles in  organizations?  Are they hard working, punctual, willing to do second (third?) drafts? 

What skills are you looking for from prospective lawyers?  

 

September 2, 2016 in Current Affairs, Legal Practice/Practice Management | Permalink | Comments (0)

Baby Boomers Driving the World....of Ride Hailing?

My dear friend and colleague Professor Mark Bauer sent me this article from the Huffington Post about the newest market share for Uber and Lyft: Boomers!  Once The Domain Of Millennials, Uber And Lyft Are Now Pursuing Seniors includes my favorite line of the day about Boomers: "It’s the Baby Boomers’ world. We’re just living in it."

"Ride-hailing services want to make sure Grandma Betty can get to bridge club just as easily as her 22-year-old grandson travels to and from ... whatever it is young folks are doing these days. ... Once the domain of 20-somethings who might have a drink or two and need a safe ride home, companies like Lyft and Uber have set their sights on a different age range entirely: senior citizens."

The article explains how the 2 companies have entered into agreements with companies-Uber with a home care company and Lyft with a company that books rides for elders without smart phones.  The article notes that there are also other ride-hailing companies beyond these 2 that are providing ride-sharing services for those elders who don't have smart phones.

The companies are boldly moving into this market demographic. In fact they've started "offering non-emergency medical transport services, specifically targeting customers whose rides would be reimbursed by Medicaid."

Consider also what Lyft is doing with the city of Centennial, Colorado, "where 15 years from now at least 30 percent of the population is projected to be over the age of 65....[C]ity officials are exploring replacing current dial-a-ride services with less expensive, more efficient rides via Lyft."

“We call Centennial the Silver Tsunami,” Centennial Mayor Cathy Noon told The Atlantic blog CityLab. “As people age, one thing to go is the ability to drive. That means losing your freedom to get to doctor’s appointments and to stay social with friends. We really want to help keep the people who started Centennial engaged in it.”

We all know how the loss of driving ability can impact a person on a number of levels. I wonder whether this transportation option will be financially feasible  enough to become  a widespread solution. If so, it will be great, because not only does this provide  transportation, but has the added benefit of socialization.  I am still holding on for the availability of self-driving cars.

 

September 2, 2016 in Consumer Information, Current Affairs, Other | Permalink | Comments (0)

Thursday, September 1, 2016

Voting by Generations

A recent report about Boomers and voting made be stop for a moment and go "hmmmm".  Pew Research Center's latest FactTank offered that this may be the last presidential election where the Greatest Generation, the Silents and the Boomers have a significant impact at the polls.

This may be the last presidential election dominated by Boomers and prior generations explains that although these demographic groups have dominated at the polls, that may no longer be true;  "their election reign may end this November, according to a new Pew Research Center analysis of census data."

[T]he ranks of Millennial and Generation X eligible voters have been growing, thanks to the aging-in of Millennials and naturalizations among foreign-born adults. These generations matched Boomers and previous generations as a share of eligible voters in 2012 and are now estimated to outnumber them. As of July, an estimated 126 million Millennial and Gen X adults were eligible to vote (56% of eligible voters), compared with only 98 million Boomers and other adults from prior generations, or 44% of the voting-eligible population.

However, keep in mind that eligible and actual are not synonymous. In fact, the article reminds us what ultimately matters is who casts ballots. Looking at the data and focusing on actual votes, the report offers that the Boomers and prior generations voted at a rate of about 70% of eligible voters. The younger generations percentage turnout was lower, according to the article.

Not that the generations are in competition or anything. It's just interesting to think about the changing demographics at the ballot box and wonder at the impact on laws and policies as a result.

Among those in the oldest living generation, the Greatest Generation, turnout crested in the 1984 election at 76% before declining. Similarly, turnout among eligible voters in the Silent Generation peaked at 76% in the 1992 election. The Millennial and Gen X generations are likely still on the upswing in terms of their turnout rates, so it is a reasonable guess that at least 54.5% of these adults will vote, and perhaps more.

We won’t know until after November if Boomers and their elders will pass the torch to Gen X and Millennials as a share of voters, but all the available data suggest that the 2016 election will mark the beginning of a new era for U.S. presidential elections.

September 1, 2016 in Consumer Information, Current Affairs, Other, Statistics | Permalink | Comments (0)

Shortages of CNAs and Qualified Staff Trigger "Relocation" Notices for NHs in Northern California

Giving more evidence of the potential impact of aging boomers in America, officials in Humboldt County, a North Coast county in California, describe potential shutdowns of three area nursing homes as potentially "catastrophic." The reason for the closures?  The problem isn't lack of residents. Operators find it difficult to attract adequate personnel, especially CNAs, needed to staff the care facilities.  From the North Coast Journal article describing the latest problem:

Rockport Healthcare Services, the management company for five of Humboldt County's six skilled nursing facilities, announced today that they have filed relocation notices for three sites: Pacific, Seaview, and Eureka Rehabilitation and Wellness Centers. The relocation notices, filed with the California Department of Public Health, are the first step in closing these facilities, which collectively contain 258 beds, and relocating their patients.

 

Stefan Friedman, spokesperson for Rockport, said in a statement that the company is continuing to work with community partners to "find a solution to [a] severe staffing crisis," but it is possible that after public health approves their relocation notice they will shut down the facilities.



That, said Area 1 Agency on Aging ombudsman Suzi Fregeau, would be "catastrophic."

 

Although many patients stay only briefly in skilled nursing facilities, receiving rehabilitation after leaving the hospital, the facilities are often the last stop for patients who cannot afford in-home healthcare professionals and need 24-hour care. Their vital role in the continuum of care was felt last year, when the facilities — five of which are owned by the same company, Brius Healthcare — stopped accepting patients. Hospital administrators, hospice workers and families all felt the pinch, and many North Coast residents had to go to facilities far away from Humboldt County. Fregeau said the potential closure will be even worse.



"It means that residents are going to be placed in facilities a minimum of 150 miles away," she said. "People are going to be dying in communities they’ve never lived in."

Sad to think that some of the prettiest areas of California are struggling with attracting and keeping adequate numbers of trained people.

September 1, 2016 in Consumer Information, Current Affairs, Health Care/Long Term Care, Housing, Medicaid, Medicare | Permalink | Comments (3)

Wednesday, August 31, 2016

ORANJ Shares Insights into Life Plan Communities

As we first reported here almost a year ago, the segment of the senior living community traditionally identified as "Continuing Care Retirement Communities" or CCRCs is working on rebranding. Under the leadership of the trade organization LeadingAge, the preferred name is Life Plan Communities.

ORANJ, the catchy acronym for the very active Organization of Residents Associations of New Jersey, publishes quarterly newsletters and their Fall 2016 issue includes demographic and marketing reasons behind the name change.  The issue includes an essay by Brian Lawrence, President and CEO of Fellowship Senior Living on Why and How Life Plan Communities Are Evolving.

August 31, 2016 in Consumer Information, Current Affairs, Health Care/Long Term Care, Housing | Permalink | Comments (1)

Tuesday, August 30, 2016

One Practitioner's Perspectives on "The Practice of Elder Law"

Stuart Bear, a practicing attorney and member of the Minnesota State Bar Association's Elder Law Section, has written an interesting first-person account of "The Practice of Elder Law" for a 2016 issue of the Mitchell-Hamline Law Review.  It turns out the 2016 piece is an updated version of a similar article he wrote for the William Mitchell Law Review in 2002, with the same title.

In both versions Bear begins with a narrative about a family member's call to ask him legal advice on how to handle care issues following an emergency hospital admission for the caller's mother. Many of the events Bear relates will resonate, both with the public (especially those of a certain age) and lawyers.

At the same time, I find that some of Bear's words -- in both versions -- could be a springboard for a broader discussion with law students and elder law specialists.  For example, he chooses to label the family member initiating the contact as "Responsible Daughter," and he refers to other siblings as "responsible sons."  What is the meaning behind this phrase?  Is he referring to "morally responsible," "financially responsible," or just generically a "good" person?  

Further, in both versions, he offers an important discussion of how he handles potential conflict of interest issues in representing the elder parent where offspring are involved in client meetings and decisions.  In the 2002 version, Mr. Bear writes about alternative choices in identifying his client:

This rule [referring to Rule 1.7 of the ABA Rules of Professional Conduct as adopted in Minnesota] is clear that should I choose Mom as my client; it is she whom I serve and no other family member. I take my marching orders based upon Mom’s goals and objectives, serving her sole interests.

 

Suppose, however, that Mom is not so definitive in articulating her goals and objectives. It may be possible for me to represent the entire family, in light of rule 2.2 of the Minnesota Rules of Professional Conduct, which addresses the lawyer as intermediary.

In the more recent 2016 version of the essay, which is the version I first encountered on Westlaw, Mr. Bear cites a different rule for his authority to represent "the family." He points to Rule 1.14 on representation of a client with "diminished capacity."  He writes:

Suppose, however, that Mom was not so definitive in articulating her goals and objectives. It may be possible for me to represent the entire family, in light of Rule 1.14 of the Minnesota Rules of Professional Conduct, which addresses clients with diminished capacity. A comment to the rule provides in pertinent part:
 
The client may wish to have family members or other persons participate in discussions with the lawyer. When necessary to assist in the representation, the presence of such persons generally does not affect the applicability of the attorney-client evidentiary privilege. Nevertheless, the lawyer must keep the client's interests foremost and . . . must look to the client, and not family members, to make decisions on the client's behalf.
 
In the situation involving Mom and Responsible Daughter, and reading the conflict of interest rule together with Rule 1.14, I may act as the lawyer for this situation, provided that no conflict of interest develops
 
Perhaps the question is whether either rule, 1.7 or 1.14, clearly authorizes the concept of "family representation" where the older client has capacity issues. While many attorneys, including elder law attorneys, do take the position this approach is appropriate, others would take the position that the daughter is acting in the role of agent or alternative decision-maker for the mother, and thus the mother is always the real party in interest, not the daughter. Neither approach eliminates the potential for conflict of interest issues for the attorney. Either way, I think the question of client identity is key to most representational roles for elder law attorneys, especially in the context of family members serving as de facto agents for their loved ones. Stuart Bear's 2002 and 2016 essays should be good food for additional thought and analysis.
 
Editing Note:  The above Blog post was edited to refer to the correct name for the Mitchell-Hamline Law Review (rather than the "Marshall-Hamline Law Review").  Our thanks to readers for catching my error! KCP

August 30, 2016 in Estates and Trusts, Ethical Issues, Health Care/Long Term Care, Legal Practice/Practice Management | Permalink | Comments (1)

Monday, August 29, 2016

PACE For Profits

PACE programs can be a great thing for certain Medicare beneficiaries, but the popularity of PACE programs hasn't seemed to grow as much as one might think. The New York Times ran a story on August 20, 2016 about the for-profit model for PACE programs. Private Equity Pursues Profits in Keeping the Elderly at Home explains  that "[u]ntil recently, only nonprofits were allowed to run programs like these. But a year ago, the government flipped the switch, opening the program to for-profit companies as well, ending one of the last remaining holdouts to commercialism in health care. The hope is that the profit motive will expand the services faster."  Is there a significant demand for PACE programs with the Boomers doing their aging thing?  Is a for-profit model the way to go to provide the type of services needed by PACE participants?

The article discusses these issues and presents both sides.  Recall that "[t]he goal of the program, known as PACE, or the Program of All-Inclusive Care for the Elderly, is to help frail, older Americans live longer and more happily in their own homes, by providing comprehensive medical care and intensive social support. It also promises to save Medicare and Medicaid millions of dollars by keeping those people out of nursing homes."

The article also discusses the possible role of tech in providing care, but notes the importance of socialization. CMS had a pilot before approving the for-profit model and is going to keep an eye on things.

The for-profit centers were approved, to little fanfare, after the Department of Health and Human Services submitted the results of a pilot study to Congress in June 2015. The demonstration project, in Pennsylvania, showed no difference in quality of care and costs between nonprofit PACE providers and a for-profit allowed to operate there.

The Centers for Medicare and Medicaid Services has vowed to closely track the performance of all PACE operators by measuring emergency room use, falls and vaccination rates, among other metrics. The National PACE Association, a policy and lobbying group, is also considering peer-reviewed accreditation to help safeguard the program. Oversight is now largely left to state Medicaid agencies.

Stay tuned.

August 29, 2016 in Cognitive Impairment, Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (0)

Training Caregivers Gets Good Results

Kaiser Health News (KHN) ran a story about the benefits of training caregivers to give care. Teaching In-Home Caregivers Seems To Pay Off  explains that "[u]nder a pilot program, nearly 6,000 aides in Los Angeles, San Bernardino and Contra Costa counties were trained in CPR and first aid, as well infection control, medications, chronic diseases and other areas. All were workers of the In-Home Supportive Services program, who are paid by the state to care for low-income seniors and people with disabilities, many of them relatives." As a result  of the training? Emergency room visits and hospital admissions were down for this group.

We all know the need for caregivers is rising. So having well-trained caregivers seems to be a no-brainer.  Yet, the article reminds us, "[t]here are currently no federal training requirements for in-home caregivers, even if they are paid with taxpayer dollars. Around the country, however, training programs have been developed and tested, according to the Paraprofessional Healthcare Institute, an advocacy group that also provides training. Among the states that have tried different types of instruction are Massachusetts, North Carolina and Michigan."  Caregivers do a lot of tasks for the elders in their care, and many caregivers are unpaid family members. But, "some states pay caregivers for eligible low-income residents through their Medicaid programs." The article offers some details about the training program. "The results of the study show that caregivers play a pivotal role in helping keep people out of the hospital...." 

August 29, 2016 in Consumer Information, Current Affairs, Health Care/Long Term Care | Permalink | Comments (0)

Where's the Beef? One University of Arizona Professor Apparently Knew....

We often report on crimes against older adults on this blog, but last week an 80-year-old former University of Arizona professor pleaded guilty to theft of more than $80,000 from  his employer. How did he accomplish that?  

The animal sciences professor was in charge of the land-grant university's "Meat Store" in Tucson and was charged with diverting thousands of dollars in proceeds from sales of meat into his own bank accounts. John Marchello worked for U of A for more than 50 years, and retired just days before his indictment in 2015. Indeed, I attended U of A many moons ago, and as a former 4-Her who took a few Ag Sciences courses along the way, I probably even took a "meats lab" course from him.  

Talk about alternative "long-term care" planning. Sadly, Marchello is scheduled to be sentenced in November and faces a potential sentence between one and three years for the Class 4 felony.

There is also a civil suit pending, alleging more than $200,000 in theft.  For more, see Longtime UA Professor Pleads Guilty.

 

August 29, 2016 in Crimes, Retirement, State Cases | Permalink | Comments (0)